Implementation of a radial long sheath protocol for radial artery spasm reduces access site conversions in neurointerventions

Abstract

BackgroundMany neurointerventionalists have transitioned to transradial access (TRA) as the preferred approach for neurointerventions as studies continue to demonstrate fewer access site complications than transfemoral access. However, radial artery spasm (RAS) remains one of the most commonly cited reasons for access site conversions. We discuss the benefits, techniques, and indications for using the long radial sheath in RAS and present our experience after implementing a protocol for routine use.MethodsA retrospective review of all patients undergoing neurointerventions via TRA at our institution from July 2018 to April 2020 was performed. In November 2019, we implemented a long radial sheath protocol to address RAS. Patient demographics, RAS rates, radial artery diameter, and access site conversions were compared before and after the introduction of the protocol.Results747 diagnostic cerebral angiograms and neurointerventional procedures in which TRA was attempted as the primary access site were identified; 247 were performed after the introduction of the long radial sheath protocol. No significant differences in age, gender, procedure type, sheath sizes, and radial artery diameter were seen between the two cohorts. Radial anomalies and small radial diameters were more frequently seen in patients with RAS. Patients with clinically significant RAS more often required access site conversion (p<0.0001), and in our multivariable model use of the long sheath was the only covariate protective against radial failure (OR 0.061, 95% CI 0.007 to 0.517; p=0.0103).ConclusionIn our experience, we have found that the use of long radial sheaths significantly reduces the need for access site conversions in patients with RAS during cerebral angiography and neurointerventions.

Radiographic clearance of chronic subdural hematomas after middle meningeal artery embolization

“…During the study period, our institution switched to a radial-first approach, which has been associated with a lower risk of complications compared with traditional femoral access, consequently making MMA embolization safer 19–27. In our study, 65 of the 84 cSDHs (77%) were treated via radial access with no major complications.…”

Transradial Access Failures During Neuroangiography for Patients With Moyamoya

“…Clinical RAS refers to arterial spasm that required an intervention to combat it. 6,7 Right TRA Techniques…”

“…If the RAS persists, the standard radial sheath is exchanged for a 23-cm long radial sheath because this has previously been shown to decrease the need for access site conversion. 7 In the event that the RAS prevents advancement of the catheter system, even after placement of a long radial sheath, then conversion to transfemoral access is considered. Figure 1 displays an example of clinically symptomatic RAS that necessitated conversion to femoral access.…”

Radial artery access for neuroendovascular procedures: safety review and complications

“…12 The incidence of radial artery spasm can also be decreased by use of a long 23 cm hydrophilic sheath because they protect the full length of the radial artery and diminish repetitive friction forces of the catheter against the vessel wall. 13 Although prevention of radial artery spasm is the preferred approach, once radial artery spasm has been detected, several techniques can be used to relieve spasm including forearm heating with forearm compresses, deepening of sedation or induction of general anesthesia, and administering additional intra-arterial vasodilators. 14 A small randomized controlled trial (RCT) (n=20) showed power injecting normal saline through the sheath (10 mL/s for 10 mL) to induce pressure-mediated vasodilation induces greater radial artery intraluminal diameter acute gain when compared with intra-arterial administration of a combination of nitroglycerin and verapamil, while causing significantly less reduction in blood pressure.…”